Report on Surgery to the Santa Clara County Medical Society

by Joseph Bradford Cox

I was at a loss to know how to account for this fluid, for there was at least a quart. I removed the bandage and examined more carefully. There was no inflammation to amount to anything, nor had there been. Here it is only the seventh day from the receipt of the injury, and it surely cannot be pus. However, to satisfy myself, I used an exploring needle; and not very much to my surprise, I discovered light colored arterial blood! Could I be mistaken? I twisted the needle about, pressed it to one side, until nearly a drachm of the blood had escaped. Fully convinced now that I had a secondary hemorrhage to deal with, the question arose what to do. I supposed that it came from one of the lumbar or inter-costal arteries that had been injured by the supposed fracture of the process of the vertebra. If so, it comes from an artery inclosed in a bony cavity, and one that cannot contract and close spontaneously, and since its origin is so close to the aorta, it will continue to bleed until the patient dies of hemorrhage.

While I was thus examining the fluctuating mass, and conjecturing as to origin and results, I fancied that the quantity of fluid was sensibly increasing. However, I will not be positive that my imagination did not assist in this accumulation.

But what shall I do? Cut down into this sinus, and hunt the bleeding artery, and tie it? Could I find it? And could I tie it if I did find it? Probably not; and more especially if it is a lumbar artery, and injured in the foramen through which it passes from the vertebra. But the man will probably bleed to death; and must I do nothing to prevent it? I concluded to use pressure with a bandage for the present, and ask for the advice of my brethren. Accordingly, compresses were placed along the spine, and the body bandaged snugly.

On returning to town, I stated the case to doctors Brown and Thorne, giving my theory for the hemorrhage,—that it was secondary, and probably from a lumbar artery. They were of opinion that it would be almost an impossibility to find the artery and tie it, and without seeing each other, concluded that pressure was the remedy to be used. I would state that at the last visit the pulse was 74, and temperature 99. This was at about 9 a.m. I visited him again about 5 p.m., and found the pulse and temperature the same. There was by this time considerable increase in the quantity of fluid. I re-adjusted my compresses and bandaged again. On Saturday morning I found the quantity of fluid about the same, perhaps slightly increased. There was now considerable inflammation of the integument, over a large part of the sinus, the skin appearing tense, and the small blood vessels distinct and purple. The patient had a slight chill last night, pulse 100, temp. 102; did not remove the compresses.

Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue furred ash-colored, countenance typhoid in expression, loss of appetite, no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp. 105.4, tongue same as yesterday, had a chill last night. The skin over the sinus is inflamed somewhat more than it was yesterday. With the advice and assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight ounces of blood was removed from the sinus, by aspiration. One hour after this operation, the pulse was 140 and the temp. 104. The specific gravity of the blood removed was 1030, and after standing for two or three hours, a grey or ash-colored sediment settled, the proportion of this being about 20 per cent. of the whole amount of the blood. This sediment consisted of corpuscles that seemed to be undergoing decomposition; they were a little larger than the red corpuscles; contained granules or spots, from three to four and seven and eight in each corpuscle. Some of them seemed to be simply swollen red blood corpuscles, ready to burst, or as it were, suppurate. If there be such a thing as inflammation of the blood,—and I believe there is,—then this change must effect the red corpuscles themselves, as to size, temperature and perhaps pain, thus supplying three of the well known characteristics of inflammation, expressed so tersely by the old latin formula, rubor, tumor, calor cum dolore. Owing to the color of the blood, the rubor, or redness, is not produced by inflammation here as it already exists.

But to return to the patient. After the blood was withdrawn, compresses were carefully applied, and the body bandaged from the lower ribs as low down as the bandage could be applied with the legs flexed at right angles to the body. The patient stood on all fours, as it is called, while the bandage was applied.

Monday, Feb. 9th, 9:30 a.m., pulse 100, temp. 103.8. There appeared to be about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 p.m., pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 a.m.,—the fluid in the sack has increased—perhaps a pint now in it, pulse 110, temp. 104. Wednesday, Feb 11th, 9:30 a.m.,—pulse 90, temp. not taken. Condition good. Ordered a laxative.

Friday, Feb 13th,—considerable inflammation over the left iliac crest, in the centre of which, a spot as large as the thumb nail, looks gangrenous. The inflammation extends over a surface as large as the two hands. Some bullae or blebs have formed in the vicinity of the gangrenous spot. Ordered a large flaxseed poultice applied, expecting an abscess would form at this place. The cathartic moved the bowels two or three times. I will here state that the patient, after the withdrawal of the blood on Sunday, was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat., three grs quinia, in a tablespoonful of glycerine and a little whisky. I afterward had the quinia made into pill and left off the iron, as the latter seemed to disagree with the stomach.

Saturday, Feb. 14th, 5 p.m.,—pulse 112, temp. 102.4. The inflammation over the left ilium is much better; but there is now as much inflammation over the right ilium as there was over the left. The fluid in the sinus has increased gradually since the evacuation of it with the aspirator. The inflammation that has now existed for two or three days over these parts of the sinus, led me to conclude that the blood which was left and that which had accumulated, had undergone decomposition and was now pus. I used an exploring needle and found this to be the case. I then introduced a trocar and canula, and drew off fifty ounces of pus, slightly tinged with blood. I re-adjusted the compresses and bandage over the sinus, hoping that a part of it at least would become obliterated before it became necessary to open it more freely.

Feb. 15th, 5 p.m.,—pulse 112, temp. 102.5. The inflammation over that part of the sinus to the right of the spine is still about the same as yesterday; also that over the left ilium. The fluid has increased during the last twenty-four hours so that there is now nearly as much as was drawn off through the canula yesterday. I concluded that further delay to a free opening was useless; consequently with the patient lying on his right side, and near the edge of the bed, I made an opening one inch long in the lower portion of the abscess,—for I now considered it one,—near the spot where the needle of the aspirator and the trocar had been previously introduced.